Educational strategies in performing cesarean section

Abstract

Cesarean section is a common operation and one of the first surgeries performed independently by trainees/residents in obstetrics and gynecology. Determination of trainees' technical skills level is dependent upon subjective faculty assessment. Based on three studies on learning curves in cesarean section, it is recommended that trainees perform between 10-15 and 40 supervised cesarean sections before operating independently. Surgical technical skills of trainees/residents may be assessed by Objective Structured Assessment of Technical Skills (OSATS), which provides a foundation for constructive feedback during surgical training. The Danish, Swedish and British Obstetric and Gynecological Societies' guidelines on cesarean section were reviewed regarding cesarean section surgical technique. Placental removal by traction on the umbilical cord is recommended uniformly; however, the Danish guidelines recommend one-layer uterine incision closure, whereas the Swedish and British guidelines recommend two-layer closure. Maternal complications at cesarean section increase when the primary surgeon is a trainee/resident rather than an experienced surgeon. Basic surgical proficiencies regarding instruments, sutures and surgical technique as well as basic anatomy, should be verified before entering a training program for cesarean section. Such a training program for technical and non-technical skills in cesarean section should include theoretical instruction, video tutorials, practical experience and direct supervision. Development of a specific OSATS for cesarean section is recommended. Training must be individually structured accommodating the differences in trainees' competencies. Before clinical training in the operating room begins, all trainees must attain standardized cognitive and technical skills.

Placenta Praevia and Placenta Accreta: Diagnosis and Management

“…Maternal complications at caesarean section increase when the primary surgeon is a trainee rather than an experienced surgeon. 89 Placenta praevia is often associated with additional complications, including fetal malpresentation (transverse or breech presentation) requiring complex intraoperative manoeuvres to deliver the baby. 90 Evidence level 4…”

“…87 There is no evidence to support the use of autologous blood transfusion for placenta praevia. 89 Cell salvage was not often used previously in obstetrics because of the perceived risk of amniotic fluid embolism or induction of maternal alloimmunisation. No definite cases of amniotic fluid embolism have been reported so far and the risks of cell salvage in the obstetric population parallel those in the nonpregnant population.…”

Incidence and risk factors of severe lacerations during forceps delivery in a single teaching hospital where simulation training is held annually

“…CS is a common operation in obstetrics and gynecology and is one of the first operations performed by trainees; however, the rate of maternal complications occurring during CS increase when the primary surgeon is a trainee. Madsen et al emphasized that structured and validated education and assessment methods should be used . Furthermore, managing patient safety during physician training is a common concern in all disciplines.…”

Inequities in resources and preparedness for surgical complications of caesarean section in southern Gauteng hospitals

“…Several immediate interventions should be considered to improve caesarean section safety at the hospitals in southern Gauteng. Most of these relate to recommendations in the national Confidential Enquiries into Maternal Deaths report from 2008 to 2010: [2] (i) human resources needs and norms must be investigated, perhaps using the Workforce Indicators of Staffing Need (WISN) approach introduced to SA in 2012, [13] to create and fill obstetric specialist and medical officer posts in the regional and district hospitals; (ii) all maternal deaths and cases of near-miss related to caesarean section bleeding should be audited and discussed at regular perinatal review meetings; (iii) training in caesarean section technique needs to be formalised at district and regional hospitals, including using training videos, with a minimum of 10 caesarean sections done under supervision before 'solo' caesarean sections can be attempted; [14] (iv) all midwives and obstetric doctors in the hospitals must be exposed to ESMOE (Essential Steps in Managing Obstetric Emergencies) training, which includes modules on surgical skills and obstetric haemorrhage; [15] and (v) sustainable emergency obstetrics outreach programmes from the central to the regional and district hospitals must be implemented and sustained, with university and provincial government support.…”